Form ATF F 5400.28 ATF F 5400.28 Employee Possessor Questionnaire

OMB No. 1140-0072

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms, and Explosives

Employee Possessor Questionnaire

Who needs to complete this form? This questionnaire MUST be completed by EACH employee
possessor of a Federal explosives licensee or permittee or applicant, unless otherwise provided. (See reverse
for definition of employee possessor.)

For ATF Use Only
RDS KEY:

Employee Possessor Information and Certification
Print the Requested Information in Block Letters.
Explosives Applicant Business or Operations Name
14. Name and address of explosives business or operations at which
1. Last Name
you are an employee possessor.
2. First Name
15. Your position in the explosives business or operations.
3. Middle Name

4. Name Suffix, if any (e.g.,
Sr., Jr., II)

16. Federal explosives license/permit number for explosives business/
operations.

5. Other Names Used - Including Maiden Name
17a. List All Countries of Citizenship.
6. Social Security Number (Voluntary, will help prevent misidentification)
If you indicated above you are a United States citizen, skip to question 18.

7. Place of Birth (City and State - or - City and Foreign Country)
8. Date of Birth (Month/Day/Year)

9. Race/Ethnicity (Check one or more boxes)
Hispanic

American Indian or
Alaskan Native
Asian

Native Hawaiian or Other
Pacific Islander

Black or African American

White

10. Sex (Check one box)
Male

Female

11. Home Telephone Number (Include area code)
12. Work Telephone Number (Include area code and extension)
Home Address
13a. Street Address

13b. Apt. Number

13c. City

13d. State - or - Province, Foreign Country
13e. ZIP Code/Postal Code

I,

17b. What is your U.S.-issued alien number or admission number?
The following questions must be answered with a “YES” or “NO”
in the left hand boxes. Use the right hand “Initials” boxes only
for a second submission (see the “Note” at the bottom of the
page.)

Yes
or
No

Renewal
Only
Initial
and
Date*

18. Are you a fugitive from justice?
19. Are you an unlawful user of, or addicted to, marijuana or
any depressant, stimulant, or narcotic drug, or any other
controlled substance?
20. Have you ever been convicted in any court of a felony, or
any other crime, for which the judge could have imprisoned
you for more than one year, even if you received a shorter
sentence, including probation?
21. Are you under indictment or information in any court for a
felony, or any crime, for which the judge could imprison you
for more than one year? (An information is a formal accusation
of a crime by a prosecutor. See Definition 1.)
22. Have you ever been adjudicated mentally defective (which
includes having been adjudicated incompetent to manage your
own affairs) or have you ever been committed to a mental
institution?
23. Have you ever been discharged from the Armed Forces under
dishonorable conditions?
24. Have you ever renounced your United States citizenship?
25. Are you an alien in the United States? If “YES,” attach an
explanatory statement if you are a lawful permanent resident.
(Generally, if you are an alien [except for a lawful
permanent resident alien], you cannot possess explosive
materials.)
Statement attached.
, certify under penalties of perjury that the answers on this questionnaire are

(Print Your Full Name)

true, correct, and complete.
Your Signature

Date

*Note: A photocopy of this form may be used for a second submission upon renewal, provided the information in questions 1-17b has not changed, the
individual initialed that all questions (18-25) are true and correct and none of the information has changed, and the individual’s signature is provided in
the space below. Do NOT complete the initial/date information if this is the first time you are filing as an employee of item #14. (See Instruction 2.)
Your Signature (For second submission)

Date
ATF Form 5400.28
Revised (
)

Instructions
1. Who must fill out and complete this form? EACH employee
possessor, as defined below, MUST personally complete this questionnaire form and certify that the answers are true, correct, and complete.
2. To whom do I submit this form? You must complete and submit this
form to your employer (applicant for license/permit). The employer
will submit this form, along with the application, to ATF. If this form
is being submitted AFTER a license or permit has been issued in order
to ADD you as an employee possessor, then the form must be accompanied by a signed letter from the licensee or permittee requesting that
you be added as an employee possessor. If this form is being submitted
for at least a second time, in relation to the same license/permit at
renewal, the employee possessor may follow instruction 3 below. In
such instance, the form should be sent to: ATF, Federal Explosives
Licensing Center, 244 Needy Road, Martinsburg, WV 25401.
3. Resubmission of form upon 3-year renewal of license/permit. In lieu
of submitting a second original form, the person listed on this form
may choose to resubmit a photocopy of the form, provided the identifying information (questions 1-17b) has not changed. Questions 18-25
must be recertified using the initials boxes, and the form must be resigned and dated.
4. Why is this form required? 18 U.S.C., Chapter 40, was amended by
the ‘Safe Explosives Act of 2002’ (the Act). The Act made it unlawful
for certain persons to ship, transport, receive, or possess explosive
materials. The Act also made it unlawful to distribute explosive
materials to certain persons. Information you provide on this form will
allow ATF to determine whether you, an employee possessor in the
explosives business or operations, are prohibited from shipping,
transporting, receiving, or possessing explosive materials. 18 U.S.C.
§ 842(d), (i).
5. Should documentation be attached to clarify a response to a question
or item? Providing additional documentation to clarify a response to a
specific question or item on the front of this form could help prevent a
delay in processing your Employer Possessor Questionnaire. Please
ensure that your name is on any attached document(s). In addition, if
your employer is renewing a Federal explosives license or permit,
ensure that the employer’s current license or permit number is on any
attached documents.
6. How do I obtain additional forms? The form can be downloaded
from ATF’s website in Adobe PDF format at www.atf.gov/forms/
index.htm. The form can be ordered using ATF’s Online Distribution
Center Order Form at www.atf.gov/dcof/index.htm. The form can also
be ordered by calling ATF’s Distribution Center at (703) 455-7801.
7. What do I do if I am prohibited from possessing explosives as
indicated above? If you are prohibited from possessing explosives,
you may request relief from your Federal explosives disability by filing
an ATF Form 5400.29, Application for Restoration of Explosives
Privileges. This form can be downloaded from ATF’s website at
www.atf.gov/forms/index.htm or may be obtained by calling (202)
927-2260/2310. Please be advised that you cannot possess explosives
until such time that relief may be granted. For example, if you are a
nonimmigrant alien, you should answer “yes” to question 25, and you
are prohibited from possessing explosives. You may file a relief
application, but you cannot possess explosives until such time that ATF
may grant you relief.
8. Need assistance in completing the form? Please review information
online concerning this form at www.atf.gov, contact the ATF Explosives
Licensing Center at (304) 616-4400, or contact your local ATF office.
Definitions
1. Under Indictment or Information or Convicted in Any Court. An
indictment, information, or conviction in any Federal, State, or local court.
2. Employee Possessor. An employee possessor is an individual who has
actual or constructive possession of explosive materials during the
course of his employment. Actual possession exists when a person is in
immediate possession or control of explosive materials (e.g., an
employee who physically handles explosive materials as part of the
production process; an employee who handles explosive materials in

order to ship, transport, or sell them; or an employee, such as a blaster,
who actually uses explosive materials). Constructive possession exists
when an employee lacks direct physical control over explosive
materials, but exercises dominion and control over the explosive
materials, either directly or indirectly through others (e.g., an employee
at a construction site who keeps keys for magazines in which explosive
materials are stored, or who directs the use of explosive materials by
other employees; or an employee transporting explosive materials from
a licensee to a purchaser).
3. Alien. An alien in the United States means any person who is not a
citizen or national of the United States.
Exceptions
1. A person who has been convicted of a felony, or any other crime, for
which the judge could have imprisoned the person for more than one
year, is not prohibited from shipping, transporting, possessing, or
receiving explosives if: (1) the conviction was properly invalidated
by a court on the basis that the conviction was unconstitutional; (2)
in the case of a Federal conviction, the person received a Presidential
pardon; or (3) ATF granted relief from Federal explosives
disabilities under 18 U.S.C. § 845(b), 27 CFR § 555.142.
2. For purposes of this form, aliens can be employee possessors if they
are lawful permanent residents. 18 U.S.C. § 842(d)(7); (i)(5).
Privacy Act Information
The following information is provided pursuant to Section 3 of the
Privacy Act of 1974, 5 U.S.C. § 552a(e)(3):
1. Authority. Solicitation of this information is made pursuant to 18 U.S.C.
§§ 842, 843. Disclosure of this information by the employee possessor
is mandatory if the employee possessor wishes to possess explosives.
2. Purpose. To determine the eligibility of the employee possessor to
possess explosive materials.
3. Routine uses. The information will be used by ATF to make determinations set forth in paragraph 2. In addition, information may be disclosed to other Federal, State, foreign, and local law enforcement and
regulatory agency personnel to verify information on the employee
possessor questionnaire and to aid in the performance of their duties
with respect to the regulation of explosives unless such disclosure is
prohibited by law. Finally, the information may be disclosed to
members of the public in order to verify the information on the
questionnaire when such disclosure is not prohibited by law.
4. Effects of not supplying the requested information. Failure to supply
complete information will delay processing and may cause denial of
the application.
5. Disclosure of social security number. Disclosure of the individual’s
social security number is voluntary. Under 18 U.S.C. §§ 842(f), 843,
and Executive Order 9397, November 22, 1943, ATF has the authority
to solicit an individual’s social security number. The number may be
used to verify the individual’s identity.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995.
The purpose of this information collection is to determine the eligibility
of the employee possessor to engage in certain operations. The information requested is required to obtain or retain a benefit and is mandatory
by statute. 18 U.S.C. § 843.
The estimated average burden associated with this collection is 20 minutes
per respondent, depending on individual circumstances. Comments
concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be addressed to Reports Management Officer,
Document Services Branch, Bureau of Alcohol, Tobacco, Firearms, and
Explosives, Washington, DC 20226.
An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid
OMB control number.
ATF Form 5400.28
Revised (

)